Health inspection·December 9, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Resident #1's Hospice B Plan of Care, dated 8/19/2025, revealed the resident was admitted for hospice services; the aide was responsible to provide urinary catheter care such as emptying the drainage bag, performing pericare, and notify if the bag was leaking; and the skilled nurse was responsible to assess the function of the indwelling urinary catheter and drainage system; and supplies Hospice B would provide included indwelling urinary catheter and drainage bag. Under the Order Section of the Hospice B Plan of Care was Resident #1 may have an indwelling urinary catheter that was to be changed every 30 days and as needed. Record review of Resident #1's nurses' note dated 09/14/2025 by LVN J revealed Hospice B was contacted due to the urinary catheter leaking, the hospice nurse came into the facility, a new catheter was inserted which was patent and draining urine which Resident #1 tolerated. In an interview on 10/04/2025 at 3:43 PM, RN A stated Resident #1 had an indwelling urinary catheter. Observation on 10/04/2025 at 3:58 PM revealed Resident #1 was in bed with an indwelling urinary catheter collection bag hung on the resident's bed frame with clear yellow urine. In a further interview on 10/04/2025 at 4:19 PM, RN A stated Resident #1 had the indwelling urinary catheter since she was admitted to hospice care because of urinary retention. RN A said initially an in-and-out catheter was done but Resident #1 still retained urine, so an indwelling urinary catheter was inserted. In an interview on 10/04/2205 at 4:22 PM, RN A reviewed Resident #1's physician's orders in the electronic clinical record, stated she did not see an order for the indwelling urinary catheter and said, I guess it's not in there. In an interview on 10/06/2025 at 1:57 PM, MDS Nurse RN H said when she completes the resident's MDS assessments, she would review the resident's clinical record, the Point of Care record, documents in the clinical record and interview the resident. MDS Nurse RN H reviewed Resident #1's Quarterly MDS assessment dated [DATE] and stated she did not mark the resident had a catheter because the resident did not have a catheter based on the resident's clinical record, the Point of Care charting completed by the CNAs. The MDS Nurse RN H was asked to review the nurse's note dated 09/14/2025 which indicated Resident #1's indwelling urinary catheter had been replaced; RN H verified the nurse noted the hospice nurse had changed the catheter and stated it was an overlook. MDS Nurse RN H stated that if she had seen the note about the urinary catheter being changed, she would have questioned the note since there was no order for the indwelling urinary catheter before marking on the MDS the resident had a urinary catheter. In an interview on 10/06/2025 from 2:10 PM to 2:55 PM, the DON said Resident #1 had the indwelling urinary catheter inserted sometime before she switched to Hospice B. The DON looked at Resident #1's physician orders, stated the resident changed to Hospice B on 08/21/2025, he didn't see any orders for the indwelling urinary catheter, and there was no documentation in the resident's clinical record that catheter care was provided. The DON looked at Resident #1's MDS Quarterly assessment dated [DATE] and stated it was not marked the resident had an indwelling urinary catheter, it should have been marked and the harm of not having the MDS completed accurately could result in the MDS being inaccurate and would need to be revised or amended. In an interview on 10/06/2025 at 3:31 PM, the Administrator said the facility had weekly interdisciplinary meetings to ensure residents' MDS assessments were completed accurately and the harm of an inaccurate MDS could result in care not being monitored. Record review of the facilities policy titled Comprehensive Assessments, revised January 2023, revealed The community conducts frequent and different types of assessments, depending on the resident's condition and need.The community uses the Resident Assessment Instrument (RAI) to develop the comprehensive resident assessment. It identifies the care, services, and treatments that each resident needs to attain or maintain his or her highest practicable mental & physical functional status. The community uses a variety of sources to obtain the information needed for the RAI, including direct observation and communication with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident, communication with licensed and non-licensed team members on all shifts, review of the resident's previous medical history and physical and medical record obtained from the referring community.Accuracy of Assessment. Each resident receives an accurate team member assessment of relevant care areas that provide team members with knowledge of each resident's status, needs, strengths, and area of decline. Record review of CMS's RAI Version 3.0 Manual, October 2025, page H-1 to page H-2, revealed under Steps for Assessment was 1. Examine the resident to note the presence of any urinary or bowel appliances. 2. Review the medical record, including bladder and bowel records, for documentation of current or past use of urinary or bowel appliances. Under Coding Instructions was Check next to each appliance that was used at any time in the past 7 days. Event ID: Facility ID: 676418 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 3 residents (Resident #1) reviewed for urinary catheters. The facility failed to ensure Resident #1's Hospice A Physician I's handwritten order for the indwelling urinary catheter that had been in place for 95 days was on the electronic physician orders; and did not document when urinary catheter care was provided or if the urinary catheter had been replaced every 30 days as ordered by Hospice B. This failure could place residents at risk for a decline in their health status.The findings included: Record review of Resident #1's admission Record, dated 10/04/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included high blood pressure, diabetes (chronic elevated levels of blood sugar which can affect other organs and bodily tissues), Parkinson's disease (progressive neurological disorder that affects, movement, balance and coordination), hypothyroidism (low blood levels of thyroid hormones) and systemic Lupus Erythematosus (a chronic autoimmune disease where the body's immune system attacks healthy tissues and organs, causing damage). Record review of Resident #1's Quarterly MDS assessment, dated 09/23/2025, revealed the resident's BIMS score was 15 out of 15, indication her cognitive skills for daily decision making were not impaired, and it was not marked the resident had an indwelling urinary catheter. Record review of Resident #1's care plans dated 10/05/2025, revealed a care plan for the focus area of At risk for infection or recurrent/chronic infection related to compromised medical condition: foley cath, initiated 05/23/2025 and revised on 10/04/2025. Record review of Resident #1's electronic clinical record Physician's Order Summary Report dated 10/04/2025 revealed an order to admit Resident #1 to Hospice A dated 06/20/2025 with no discontinue date, and another order to admit to Hospice B dated 8/21/25 with diagnoses of Parkinson's disease; and there was no order for an indwelling urinary catheter. Record review of Resident #1's electronic clinical record under the Miscellaneous section revealed a New Order Form dated 06/30/2025 with a handwritten order from Hospice A Physician I to Place Foley [urinary] cath [catheter] for [urinary] retention and an order for an antibiotic (Cipro 500 mg) to be administered by mouth twice a day for 10 days for diagnosis of Urinary Tract Infection, and was signed by Hospice A Physician I. Record review of Resident #1's electronic clinical record under the Miscellaneous section revealed a Hospice A Meeting Review note, dated 07/01/2025, which noted on 06/30/2025 Resident #1 was complaining of symptoms of urinary retention. Resident #1 wanted an in-and-out catheter which was placed and left for urinary retention. Resident #1 had over 1 L [Liter] of urine retention. Her urine was cloudy. Cipro 500 mg bid [twice a day] x 10 days started. Record review of Resident #1's Hospice A Nursing Clinical Notes, dated 07/02/2025, 07/07/2025, and 07/10/2025 revealed Resident #1 had an indwelling urinary catheter. Record review of Resident #1's Hospice B admission Orders, dated 08/19/2025, revealed she was admitted with hospice diagnosis of Parkinson's disease, and an order for the indwelling urinary catheter was not listed. Record review of Resident #1's Hospice B Facility and Hospice Delineation of Duties Plan of Care, dated 08/19/2025, revealed both Hospice B and the facility were responsible to provide indwelling urinary catheter care, insertion, and change the catheter. Record review of Resident #1's Hospice B Plan of Care, dated 8/19/2025, revealed the resident was admitted for hospice services; the aide was responsible to provide urinary catheter care such as emptying the drainage bag, performing pericare, and notify if the bag was leaking; and the skilled nurse was responsible to assess the function of the indwelling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few urinary catheter and drainage system; and supplies Hospice B would provide included indwelling urinary catheter and drainage bag. Under the Order Section of the Hospice B Plan of Care was Resident #1 may have an indwelling urinary catheter that was to be changed every 30 days and as needed. Record review of Resident #1's July 2025 MAR/TAR revealed Resident #1 received the antibiotic Cipro 500 mg twice a day by mouth for 10 days and there was no documentation of indwelling urinary catheter care or if the indwelling urinary catheter had been replaced. Record review of Resident #1's August 2025 MAR/TAR revealed there was no documentation of an indwelling urinary catheter care or if the indwelling urinary catheter had been replaced. Record review of Resident #1's September 2025 MAR/TAR revealed there was no documentation of an indwelling urinary catheter care or if the indwelling urinary catheter had been replaced. Record review of Resident #1's October 2025 MAR/TAR revealed there was no documentation of an indwelling urinary catheter care from 10/01/2025 to 10/04/2025. Record review of Resident #1's nurses' notes from 06/30/2025 to 10/04/2025 revealed the resident did not have any further urinary tract infections and she was not hospitalized . Record review of Resident #1's nurses' note dated 09/14/2025 by LVN J revealed Hospice B was contacted due to the urinary catheter leaking, the hospice nurse came into the facility, a new catheter was inserted which was patent and draining urine which Resident #1 tolerated. Record review of Resident #1's nurses' note dated 10/03/2025, created on 10/04/2025 at 4:24 PM by RN A revealed Hospice B nurse came into facility per resident request to replace foley [indwelling urinary catheter]. Foley 16fr [size of catheter inserted] was placed successfully by hospice nurse. In an interview on 10/04/2025 at 3:43 PM, RN A stated Resident #1 had an indwelling urinary catheter. Observation on 10/04/2025 at 3:58 PM revealed Resident #1 was in bed with an indwelling urinary catheter collection bag hung on the resident's bed frame with clear yellow urine. In a further interview on 10/04/2025 at 4:19 PM, RN A stated Resident #1 had the indwelling urinary catheter since she was admitted to hospice care because of urinary retention. RN A said initially an in-and-out catheter was done but Resident #1 still retained urine, so an indwelling urinary catheter was inserted. RN A stated, it was replaced yesterday by Hospice B [nurse] and I flushed it today and it looked good. When asked where she documented it, RN then asked the surveyor if she should have documented it and before the surveyor could respond, RN A stated she would write a late note about the indwelling urinary catheter being replaced by hospice services. In an interview on 10/04/2205 at 4:22 PM, RN A reviewed Resident #1's physician's orders in the electronic clinical record, stated she did not see an order for the indwelling urinary catheter and said, I guess it's not in there. In an interview on 10/05/2025 from 2:25 PM to 2:41 PM, NAIT B said Resident #1 had an indwelling urinary catheter that she would empty the collection bag about five times a day and clean the catheter when pericare was provided to the resident. In an interview on 10/05/2025 from 4:31 PM to 4:52 PM with CNA C and CNA D, who was translating for CNA C, revealed when CNA C provided incontinent care to Resident #1, he would empty the urinary catheter bag and perform catheter care. In an interview on 10/05/2025 from 4:57 PM to 5:14 PM, LVN E stated she would check Resident #1's urinary catheter and bag, empty the bag several times during the shift and would clean the catheter tubing. LVN E stated the hospice nurse would change Resident #1's indwelling urinary catheter. In an interview on 10/06/2025 from 1:40 PM to 1:55 PM, MA G stated he had been a MA for 1 week and previously was a CNA who had cared for Resident #1. MA G said when he provided care to Resident #1, he would empty the urinary collection bag, and clean the catheter tubing when pericare was provided to the resident. In an interview on 10/06/2025 at 9:04 AM, Resident #1's Private Sitter F stated she has been the resident's private sitter for about 1 year before the resident was admitted to the facility and had been coming to the facility for about four months for 12 hours a day. Private Sitter F stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete nurses and CNAs would come in to clean up the resident and take care of the resident's indwelling urinary catheter. In an interview on 10/06/2025 from 2:10 PM to 2:55 PM, the DON said Resident #1 had the indwelling urinary catheter inserted sometime before she switched to Hospice B. The DON looked at Resident #1's physician orders, stated the resident changed to Hospice B on 08/21/2025, he didn't see any orders for the indwelling urinary catheter, and there was no documentation in the resident's clinical record that catheter care was provided. The DON stated the harm of not having an order for an indwelling urinary catheter or not documenting catheter care was that the care could be missed. In an interview on 10/06/2025 at 3:31 PM, the Administrator said the harm of not having an order for an indwelling urinary catheter was that it could potentially be missed for monitoring for changes to the catheter. The Administrator said they have daily clinical meetings in the morning and weekly interdisciplinary team meetings to review residents' care to ensure accuracy of orders. Record review of the facility's policy Incontinence and Catheterization Assessment and Evaluation, revised January 2023, revealed Assessments are based on the resident's RAI, history, and physical, and other information such as physician orders, progress notes, nurses' notes, pharmacist reports, lab reports, and any flow sheets used to document the resident's voiding history.For a resident who was admitted to the community with an indwelling urinary catheter or who had one placed after admission, the community will: Recognize and assess factors affecting the resident's urinary function and identified the medical justification for the use of an indwelling urinary catheter; Define and implement pertinent interventions consistent with resident conditions, goals and recognized standards of practice to try to minimize complications from an indwelling urinary catheter and remove it if clinically indicated; Monitor and evaluate the resident's response to interventions; Revise the approaches as appropriate. Event ID: Facility ID: 676418 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 8 residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's electronic clinical record had Hospice A Physician I's handwritten order for the indwelling urinary catheter, that had been in place for 95 days and did not discontinue the order for Hospice A when the resident admitted to Hospice B. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. The findings included: Record review of Resident #1's admission Record, dated 10/04/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included high blood pressure, diabetes (chronic elevated levels of blood sugar which can affect other organs and bodily tissues), Parkinson's disease (progressive neurological disorder that affects, movement, balance and coordination), hypothyroidism (low blood levels of thyroid hormones) and systemic Lupus Erythematosus (a chronic autoimmune disease where the body's immune system attacks healthy tissues and organs, causing damage). Record review of Resident #1's Quarterly MDS assessment, dated 09/23/2025, revealed the resident's BIMS score was 15 out of 15, indication her cognitive skills for daily decision making were not impaired, and it was not marked the resident had an indwelling urinary catheter. Record review of Resident #1's care plans dated 10/05/2025, revealed a care plan for the focus area of At risk for infection or recurrent/chronic infection related to compromised medical condition: foley cath, initiated 05/23/2025 and revised on 10/04/2025. Record review of Resident #1's electronic clinical record Physician's Order Summary Report dated 10/04/2025 revealed an order to admit Resident #1 to Hospice A dated 06/20/2025 with no discontinue date, and another order to admit to Hospice B dated 8/21/25 with diagnoses of Parkinson's disease; and there was no order for an indwelling urinary catheter. Record review of Resident #1's electronic clinical record under the Miscellaneous section revealed a New Order Form dated 06/30/2025 with a handwritten order from Hospice A Physician I to Place Foley [urinary] cath [catheter] for [urinary] retention and an order for an antibiotic (Cipro 500 mg) to be administered by mouth twice a day for 10 days for diagnosis of Urinary Tract Infection, and was signed by Hospice A Physician I. Record review of Resident #1's electronic clinical record under the Miscellaneous section revealed a Hospice A Meeting Review note, dated 07/01/2025, which noted on 06/30/2025 Resident #1 was complaining of symptoms of urinary retention. Resident #1 wanted an in-and-out catheter which was placed and left for urinary retention. Resident #1 had over 1 L [Liter] of urine retention. Her urine was cloudy. Cipro 500 mg bid [twice a day] x 10 days started.Record review of Resident #1's Hospice A Nursing Clinical Notes, dated 07/02/2025, 07/07/2025, and 07/10/2025 revealed Resident #1 had an indwelling urinary catheter.Record review of Resident #1's Hospice B admission Orders, dated 08/19/2025, revealed she was admitted with hospice diagnosis of Parkinson's disease, and an order for the indwelling urinary catheter was not listed. Record review of Resident #1's Hospice B Facility and Hospice Delineation of Duties Plan of Care, dated 08/19/2025, revealed both Hospice B and the facility were responsible to provide indwelling urinary catheter care, insertion, and change the catheter.Record review of Resident #1's Hospice B Plan of Care, dated 8/19/2025, revealed the resident was admitted for hospice services; the aide was responsible to provide urinary catheter care such as emptying the drainage bag, performing pericare, and notify if the bag was leaking; and the skilled nurse was responsible to assess the function of the indwelling urinary catheter and drainage system; and supplies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Hospice B would provide included indwelling urinary catheter and drainage bag. Under the Order Section of the Hospice B Plan of Care was Resident #1 may have an indwelling urinary catheter.Record review of Resident #1's nurses' notes from 06/30/2025 to 10/04/2025 revealed the resident did not have any further urinary tract infections and she was not hospitalized . Record review of Resident #1's nurses' note dated 09/14/2025 by LVN J revealed Hospice B was contacted due to the urinary catheter leaking, the hospice nurse came into the facility, a new catheter was inserted which was patent and draining urine which Resident #1 tolerated. Record review of Resident #1's nurses' note dated 10/03/2025, created on 10/04/2025 at 4:24 PM by RN A revealed Hospice B nurse came into facility per resident request to replace foley [indwelling urinary catheter]. Foley 16fr [size of catheter inserted] was placed successfully by hospice nurse. In an interview on 10/04/2025 at 3:43 PM, RN A stated Resident #1 had an indwelling urinary catheter. Observation on 10/04/2025 at 3:58 PM revealed Resident #1 was in bed with an indwelling urinary catheter collection bag hung on the resident's bed frame with clear yellow urine. In a further interview on 10/04/2025 at 4:19 PM, RN A stated Resident #1 had the indwelling urinary catheter since she was admitted to hospice care because of urinary retention. RN A said initially an in-and-out catheter was done but Resident #1 still retained urine, so an indwelling urinary catheter was inserted. RN A stated, it was replaced yesterday by Hospice B [nurse] and I flushed it today and it looked good. When asked where she documented it, RN then asked the surveyor if she should have documented it and before the surveyor could respond, RN A stated she would write a late note about the indwelling urinary catheter being replaced by hospice services. In an interview on 10/04/2205 at 4:22 PM, RN A reviewed Resident #1's physician's orders in the electronic clinical record, stated she did not see an order for the indwelling urinary catheter and said, I guess it's not in there. In an interview on 10/06/2025 from 2:10 PM to 2:55 PM, the DON said Resident #1 had the indwelling urinary catheter inserted sometime before she switched to Hospice B. The DON looked at Resident #1's physician orders, stated the resident changed to Hospice B on 08/21/2025, he didn't see any orders for the indwelling urinary catheter, and there was no documentation in the resident's clinical record that catheter care was provided. The DON stated the harm of not having an order for an indwelling urinary catheter or not documenting catheter care was that the care could be missed. In an interview on 10/06/2025 at 3:31 PM, the Administrator said the harm of not having an order for an indwelling urinary catheter was that it could potentially be missed for monitoring for changes to the catheter. The Administrator said they have daily clinical meetings in the morning and weekly interdisciplinary team meetings to review residents' care to ensure accuracy of orders. Record review of the facility's policy Medical Records, revised January 2023, revealed A medical record is maintained for every person admitted to a community in accordance with accepted professional standards and practices. The administrator has ultimate responsibility for the maintenance of medical records but may delegate this responsibility to another team member. The medical record consists of but not limited to the following: information to identify the resident, a record of the resident's assessments, the plan of care and services provided. Event ID: Facility ID: 676418 If continuation sheet Page 8 of 8